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Choosing Wisely – Investigations for Paediatric Patients presenting with Psychiatric Symptoms

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The Choosing Wisely® campaign aims to promote collaborative conversations between clinicians and families to safely avoid unnecessary and potentially harmful tests.

A list of five key recommendations for Paediatric Emergency Medicine was created by the American Academy of Paediatrics Section on Emergency Medicine (AAP SOEM) following a structured review process and expert consensus opinion.

This series of DFTB articles aims to increase awareness of the Choosing Wisely® recommendations, with each article taking a deeper dive into supporting evidence and practical implications of each recommendation.

Do not obtain screening laboratory tests in the medical clearance process of paediatric patients who require inpatient psychiatric admission unless clinically indicated.

14-year-old Katy presents to the paediatric Emergency Department (ED), alone, complaining of suicidal ideation.

While performing HEADSSS assessment, she admits to having thoughts about harming herself during the last few months after being bullied at school.

During your assessment, the young persons’ mental health team arrives and asks you whether any blood tests need to be done.

What is the problem?

Mental health-related ED visits for children and young people are common and have been on the rise during the last decade. A 2022 CDC report showed an overall trend of increasing mental health-related ED visits for children and young people aged 0-17 from 2019 to 2022. This was particularly notable during the COVID-19 pandemic, with a retrospective cohort study of mental-health-related ED visits at a single-centre observing a 44% increase in mental-health-related ED visits amongst children and young people.

Acute-onset psychosis may be secondary to an underlying medical cause, especially in adults. It can be difficult to diagnose and may require detailed investigation. However, children and young people more commonly present with either behavioural problems or suicidal ideation.

Medical screening of children in the ED with mental health-related presentations is often requested before inpatient admission. The intent of medical screening is not just to identify and treat medical conditions that might be leading to the symptoms (such as encephalitis) but also to ensure that any underlying medical conditions will be able to be safely managed in a psychiatric unit, as many of these units have limited ability to care for complex medical problems. This usually includes complete blood count, basic metabolic panel (e.g., electrolytes, liver function tests), thyroid function, screening for potential drug use, urinalysis, electrocardiogram, and neuroimaging (e.g., CT head). However, the evidence behind medical screening in children is limited.

What do the guidelines say?

The American College of Emergency Physicians and the American Academy of Paediatrics (AAP) suggest screening laboratory tests should only be performed in children and young people with supporting evidence from their clinical examination and medical/psychiatric history. Screening laboratory tests are not recommended in children with normal vital signs and clinical examination.

What is the evidence for avoiding laboratory testing?

A recent systematic review, including adults and paediatric patients, showed that although laboratory abnormalities may be present in up to 41% of patients, only around 0.4% were clinically significant and changed patient management.

A single-centre retrospective US study reported similar results, including 1,082 children. Another study observed that children and young people who received unnecessary medical screening laboratory investigations would have received definitive psychiatric care on average 6.8 hours earlier had these not been undertaken.

Overall, the evidence suggests that screening laboratory tests offer little information above a careful history and examination. Avoiding routine screening for psychiatric presentations in children and young people can decrease the time to appropriate psychiatric care, decrease ED length of stay and bed occupancy, and avoid the distress that can be caused by undertaking investigations and from being in the ED environment.

Which children should we be requesting laboratory testing for?

Laboratory tests should only be ordered based on the clinical suspicion from the history and examination. These include children with abnormal vital signs, altered mental status, evidence of disorientation, history of significant head trauma and abnormal neurological examination. Moreover, laboratory investigation may assist in reaching a diagnosis in paediatric patients with known comorbidities and potential toxidromes. Investigations may also be necessary for the assessment of severe self-harm (such as deep lacerations or hanging) or the evaluation of potential sexual abuse.

How can we reduce medical clearance in paediatric patients?

A 2023 Quality Improvement (QI) project involved the introduction of a medical clearance algorithm for children presenting with psychiatric emergencies. The stepwise approach was guided by vital signs, presence of seizures or focal neurology, presence of trauma (including attempted hanging or cutting), overdoses and substance misuse, level of consciousness, medical complaints, history of alleged sexual assault/rape, and developmental delay. This was presented as a simple algorithm.  Following implementation, there was a significant reduction in the number of children receiving laboratory investigation, from 93% before (547/589) implementation to 19.6% (158/807) afterwards.

This decrease was not associated with more young people needing medical treatment, and there were no transfers for medical services.

What should we say to parents and caregivers?

Recognising and acknowledging the child’s stress and traumatic experience in the ED is important. Parental concerns should be addressed appropriately. Parents and caregivers should be reassured that since their child has normal vital signs and physical examination, further investigations are unlikely to provide any further information about the history and examination or change their child’s management.

Even though investigations are unlikely to change management, they can cause unnecessary distress and increase the amount of time spent in the ED and delay psychiatric care. Discussions with parents should be supported by patient information materials, particularly the provision of information in multiple languages.

Take Home Points

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References

Beaudry G, Drouin O, Gravel J, et al. A comparative analysis of pediatric mental health-related emergency department utilization in Montréal, Canada, before and during the COVID-19 pandemicAnn Gen Psychiatry. 2022;21(1):17. Published 2022 Jun 13. https://doi.org/10.1186/s12991-022-00398-y 

Berg JS, Payne AS, Wavra T, Morrison S, Patel SJ. Implementation of a Medical Clearance Algorithm for Psychiatric Emergency Patients. Hosp Pediatr. 2023;13(1):66-71. https://doi.org/10.1542/hpeds.2022-006672

Chun TH. Medical clearance: time for this dinosaur to go extinct. Ann Emerg Med. 2014;63(6):676-677. https://10.1016/j.annemergmed.2013.11.012

Chun TH, Mace SE, Katz ER. Evaluation and Management of Children and Adolescents With Acute Mental Health or Behavioral Problems. Part I: Common Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies. Pediatrics. 2016;138(3):e20161570. https://doi.org/10.1542/peds.2016-1570

Conigliaro A, Benabbas R, Schnitzer E, Janairo MP, Sinert R. Protocolized Laboratory Screening for the Medical Clearance of Psychiatric Patients in the Emergency Department: A Systematic Review. Acad Emerg Med. 2018;25(5):566-576. https://doi.org/10.1111/acem.13368

Donofrio JJ, Horeczko T, Kaji A, Santillanes G, Claudius I. Most routine laboratory testing of pediatric psychiatric patients in the emergency department is not medically necessary. Health Aff (Millwood). 2015;34(5):812-818. https://doi.org/10.1377/hlthaff.2014.1309

Donofrio JJ, Santillanes G, McCammack BD, et al. Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance. Ann Emerg Med. 2014;63(6):666-75.e3. https://doi.org/10.1016/j.annemergmed.2013.10.011 

Radhakrishnan L, Leeb RT, Bitsko RH, et al. Pediatric Emergency Department Visits Associated with Mental Health Conditions Before and During the COVID-19 Pandemic – United States, January 2019-January 2022. MMWR Morb Mortal Wkly Rep. 2022;71(8):319-324. Published 2022 Feb 25. https://doi.org/10.15585/mmwr.mm7108e2

Santillanes G, Donofrio JJ, Lam CN, Claudius I. Is medical clearance necessary for pediatric psychiatric patients?. J Emerg Med. 2014;46(6):800-807. https://doi.org/10.1016/j.jemermed.2013.12.003

Tagg A. Mental Health Screening. Don’t Forget The Bubbles. 2019. Available at https://doi.org/10.31440/DFTB.21114

Thrasher TW, Rolli M, Redwood RS, Peterson MJ, Schneider J, Maurer L, Repplinger MD. ‘Medical Clearance’ of Patients With Acute Mental Health Needs in the Emergency Department: A Literature Review and Practice Recommendations. WMJ. 2019 Dec;118(4):156-163. PMID: 31978283; PMCID: PMC7215859.

Santiago LI, Tunik MG, Foltin GL, Mojica MA. Children requiring psychiatric consultation in the pediatric emergency department: epidemiology, resource utilization, and complications. Pediatr Emerg Care. 2006;22(2):85-89. https://doi.org/10.1097/01.pec.0000199568.94758.6e

All articles were reviewed and edited by Spyridon Karageorgos.

Authors

  • Spyridon is a Paediatric Resident in Athens, interested in Paediatric Emergency Medicine, reducing antibiotic use in paediatric patients and in Medical Education. Currently studying on the QMUL PEM MSc. He/him.

  • Owen Hibberd is an Emergency Medicine Trainee in Cambridge, currently studying on the QMUL PEM MSc. Interested in Paediatric Emergency Medicine, Pre-Hospital Emergency Medicine and Medical Education. He/him.

  • Brad Sobolewski, MD, MEd is an Associate Professor of Pediatric Emergency Medicine and an Associate Director for the Pediatric Residency Training Program at Cincinnati Children's Hospital Medical Center. He is on Twitter/X as @PEMTweets and authors the Pediatric Emergency Medicine site PEMBlog and is the host of PEM Currents: The Pediatric Emergency Medicine Podcast.

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